The use of antibiotics during pregnancy: A cross‐sectional study of knowledge, attitude, and practices among antenatal care attendees in Northern Ghana

Abstract Background and aims The promotion of rational use of antibiotics among pregnant women is eminent not only for the risk of teratogenicity in the developing fetus but also the risk of drug resistance with its concomitant high cost of health care. Studies on antibiotic self‐medication among pregnant women in Northern Ghana are rare. Improving the knowledge and awareness among the vulnerable groups about the appropriate use of antibiotics can help in limiting the antibiotic resistance menace. We, therefore, conducted this study to assess the knowledge, attitude, and practice (KAP) toward antibiotic use among pregnant women attending an antenatal clinic at a primary health care in Tolon, Northern Region, Ghana. Method We conducted a cross‐sectional study using an interviewer‐administered questionnaire to assess the KAP of 702 pregnant women on antibiotic use. This study was conducted in the Tolon Health Center (THC) from March 2021 and ended in October 2021. Results In this study, 55.6% of pregnant women had good knowledge and 45.3% of them had engaged in self‐medication with antibiotics while pregnant. There were statistically significant associations between participants' background and obstetric characteristics and knowledge of antibiotic use and antibiotic resistance, except for age, marital status, and parity. Also, there was a significant association between pregnant women's knowledge and self‐medication or over‐the‐counter purchase of antibiotics. Conclusion We concluded that higher education level, monthly income, good practice, and good knowledge were significantly associated with a reduced likelihood of self‐medication with antibiotics. A well‐structured education that could be easily accepted and understood by pregnant women on the risks of antibiotic self‐medication should be included in the routine education at the antenatal clinics.


| INTRODUCTION
Antibiotic resistance has become a worldwide health challenge associated with the rise in antibiotic prescription and consumption worldwide. 1This challenge has a serious consequence on humans, as diseases that were easily treatable will be difficult to treat. 2 Among many, self-medication is a major contributor to the development of human pathogen resistance to antibiotic drugs. 2,3egnant women are one of the vulnerable population groups who practice self-medication frequently and repeatedly for the prevention of abortion and treatment of pregnancy-related morbidities. 4ring pregnancy, many physiological and hormonal changes occur, which make these women susceptible to infection, 5 which if not managed timely and well, may lead to some complications that may be fatal to the mother or fetus. 6,7To bring quick relief from these pregnancy-related symptoms, pregnant women may resort to using medicines.10] Self-medication during pregnancy presents a serious maternal and fetal health threat that cannot be overemphasized. 11,12It may lead to fetal toxicity, low birth weight, preterm delivery, and also other teratogenic effects. 10,13Sub-Saharan Africa accounted for ~66% of the estimated global maternal deaths in 2017. 14Many studies have indicated high rates of self-medication during pregnancy, 4,9,[15][16][17][18][19] with self-medication with antibiotics among pregnant women reported as 1.9% in Tanzania 16 and 9.6% in Nigeria. 19However, a study in Ghana reported that the prevalence of antibiotic exposure among pregnant women increased from 54.8% in 2013 to 77.8% in 2015. 12Antibiotic exposures during pregnancy have been associated with both short-term (e.g., congenital abnormalities) and long-term effects (e.g., changes in the gut microbiome, asthma, atopic dermatitis) in the newborn.However, it is estimated that only 10% of medications have sufficient data related to safe and effective use by pregnant women. 20Widespread irrational use of antibiotics and ignorance of people about the need to complete the course of antibiotics, their side effects, standard acceptable dosage limits, and antibiotic overdose issues can lead to microbial resistance issues. 2e promotion of rational antibiotic use is imminent due to the risk of drug resistance with its concomitant high cost of health care and also the risk of teratogenicity in the developing fetus. 12Even though there are many potential dangers associated with antibiotic self-medication during pregnancy, 21,22 many pregnant women are oblivious of them. 17Improving the knowledge and awareness among the nonmedical population about the usage of antibiotics can help in limiting the antibiotic resistance menace. 2,3port on pregnant women's knowledge, attitudes, and antibiotic use is rare in Ghana, especially in the Northern Region.To speed up the antibiotic stewardship campaign in Northern Ghana and implementation of appropriate interventions, a potential knowledge gap concerning antibiotic use in pregnancy and associated factors must be identified.We, therefore, conducted this study to assess the knowledge, attitude, and practice (KAP) toward antibiotic use among pregnant women attending an antenatal clinic at a primary health care in Tolon, Northern region, Ghana.

| Study design and setting
This cross-sectional study conducted among antenatal attendees at the Tolon Health Center (THC) within the Northern Region of Ghana.This was conducted between May 2021 to October 2021.

| Study population and eligibility criteria
The study participants were all pregnant women receiving antenatal care (ANC) at THC during the study period.Only pregnant women who gave informed consent were included in the studies.For those below 18 years, their legal guardian or parent consented for them.

| Sample size calculation
We used the Yamane's formula to determine the minimum number of participants required for the study.The formula stated that n = N/ 1 + Ne 2 ; where n is the sample size required, N is the known population size, e represents the error (0.05) at a confidence level of 95%.Using a population size of 118,101, the minimum number of participants required for the study was 399.

| Sampling methods
We used a simple random technique to select study participants.The facility was visited twice in a week.For each day of visit, a maximum of 15 pregnant women were recruited for the study.In all, we recruited 702 pregnant women over the 6-month period.

| Data collection instrument
We used an interviewer-administered questionnaire, which was adapted from other studies, 15,24 to establish the KAPs of pregnant women regarding antibiotic use.The questionnaire constitutes a section for socio-demographic and obstetric characteristics, KAP.
The internal consistency of questions for knowledge sections that were scored was assessed and Cronbach's α value of 0.80 was obtained.
Three trained midwifery students with the supervision of a medical officer administered the questionnaires.The questionnaires were pretested before being used.Antenatal attendees who consented by signing or thumbprinting or through their guardian were recruited into the study.The questionnaire was translated to the respondent's local dialect by a language competent midwife when necessary.

| Variables
The variables of interest socio-demographic and obstetric history, KAP regarding antibiotic use.
The main outcomes of interest were knowledge score, desired attitude, and desired practice of antibiotic use.Knowledge score was determined as the number of questions answered correctly out of the total questions.Knowledge score above the mean knowledge score was considered as good knowledge. 15For attitude and practice, we calculated the total desired answers and reported them in frequencies.Purchase and use of antibiotics without prescription was considered as self-medication.
Socio-demographic and obstetric history, knowledge, and attitude were tested as the main predictors of antibiotic use among the pregnant women.

| Data analysis
First, the data entry team checked for the completeness of the questionnaire.Incomplete questionnaires were excluded from analysis.Data were then entered into Microsoft Excel 2019, cleaned, and exported to SPSS version 26 for analysis.For descriptive statistics, frequencies and percentages were used.
Logistic regression was used to detect predictors of antibiotic selfmedication and odds ratio, 95% confidence interval (CI), and p = 0.05 were used.

| Ethical considerations
Permission for the study was obtained from the administrator of the facility.Ethical approval was obtained from University for Development Studies Institutional Review Board with reference UDS/RB/ 0006/21.The interviews were conducted in privacy and all information was kept confidential.

| Demographic and obstetrics characteristics of participants
As seen in Table 1, participants' age ranged from 16 to 45 years with a mean age of 25.2 ± 3.81 years.Most (54.7%) of the participants were from the age of 21 to 30 years and 660 (94.0%) were married.In terms of monthly income, 61.4% earned <Gh¢500.00 with 12.8% earning over Gh¢2000.00.Among the 702 pregnant women, 24.8% had no formal education and 29.9%, 32.5%, and 12.8% had completed primary, secondary, and tertiary school education, respectively.Also, in the study were 138(19.7%)nulliparous, 198(28.2%)were primiparous, 342(48.7%)multiparous, and 24(3.4%)grand multiparous women.Three hundred and eighteen (45.3%) of the pregnant women were in their second trimester with an average number of gravidae of 2.85 ± 1. 264 and 264 (37.6%) had lost a pregnancy.

| Knowledge of antibiotic use among pregnant women
We used nine questions to assess participants' knowledge of antibiotic usage during pregnancy and antibiotic resistance.The mean knowledge score was 6.5 ± 1.2., which was the minimum score for good knowledge.Three hundred and ninety (55.6%) had good knowledge.More than half of the participants, 54.7% and 66.7% knew that antibiotics are not used to treat headaches and cough, and antibiotics can be used to treat flu, respectively.Also, 91.5% knew that antibiotic resistance is when an antibiotic is unable to kill germs and 94.9% knew that resistance is a serious health issue (Figure 1).There were statistically significant associations between participants' background and obstetric characteristics and knowledge of antibiotic use and antibiotic resistance, except for age (p = 0.435), marital status (p = 0.109), and parity (p = 0.262).Also, there was a significant association between pregnant women's knowledge and self-medication or over-the-counter purchase of antibiotics (Table 1 and Figure 1).

| Attitudes of pregnant women towards antibiotic use
Six hundred (85.5%) participants agreed that pregnant women need to consult a doctor before taking antibiotics.However, only 75.2% agreed that pregnant women should not buy any antibiotics over the counter.Also, 55.6% agreed it is not good to accept antibiotics from family members to treat infection (Figure 2).

| Practices of pregnant women regarding antibiotics
In this study, 45.3% of the women reported having engaged in selfmedication through the purchase of unprescribed antibiotics over the counter whiles pregnant.Only 43.6%, completed the course of antibiotic regimen for treatment and 54.7% do not keep antibiotics at home (Figure 3).

| Predictors of knowledge of antibiotic use and resistance among pregnant women
To identify the predictors of knowledge among pregnant women, we performed a logistic regression analysis to compare participants' demography and knowledge score (Table 2.) The regression model analysis reveals that pregnant women who have had primary secondary and tertiary education were 16  F I G U R E 2 Percentage of responses from all respondents to statements surrounding attitudes towards antibiotic use.

| Predictors of antibiotic self-medication in pregnant women
As indicated in Table 3, education, monthly income, good practice, and good knowledge were significantly associated with a reduced likelihood to self-medicate.Pregnant women who have had primary, secondary and tertiary had 0.2679 (CI: 0.1707-0.4152;p < 0.001), 0.1296 (CI: 0.08330-0.2039;p < 0.001), and 0.1157 (CI: 0.06585-0.2070;p < 0.001) reduced odd of self-medicating with antibiotics.Also, we found out that an increase in monthly income is associated with decreased odds of self-medication.
Those who earned Gh¢1000-1499, Gh¢1500-1999, and Gh¢ 2000, or more had reduced odds of 0.05329 (CI: 0.02415-0.1279;p < 0.001), 0.1563 (CI: 0.09444-0.2591;p < 0.001), 0.04187 (CI: 0.01918-0.09848;p < 0.001), respectively.We realized that desired practice of completing the course of the regimen of antibiotics for treatment was associated with a 58.4% decrease in the odds of self-medication with antibiotics.Those who keep unprescribed antibiotics at home were 2.69 (CI: 1.989-3.672;p < 0.001) times more likely to engage in self-medication with antibiotics.Those who had good knowledge were associated with an 86.8% decrease in odds of self-medication.

| DISCUSSION
This study was conducted to assess the KAP of antibiotic use and the prevalence of antibiotic self-medication among pregnant women receiving ANC in a primary health facility in Northern Ghana.
In this study, 55.6% of pregnant women had good knowledge of antibiotic use and resistance, which is however lower than the 80% reported among pregnant women in South Africa. 155][26] In this study, 45.3% of the women reported having purchased antibiotics over the counter without a prescription while pregnant.This rate is in contrast to the 16.6% in South Africa, 15 12.5%, and 25.1% in Ethiopia, 27,28 and 37% in Nigeria 9 that has been reported among pregnant women.Reasons attributed to self-medication include the urge for self-care, feeling of sympathy toward family members in sickness, lack of time, lack of health services, financial constraint, ignorance, misbelieves, extensive advertisement, and availability of drugs in informal channels are responsible for the growing trend of self-medication. 8,29e antibiotic resistance crisis is not only a health threat to the healthcare industry but also an economic burden for both developed and developing economies.The consequences of antibiotic resistance on patient care is dire and cannot be estimated especially in resource limited countries including Ghana. 11,30A major reason responsible for the antibiotic resistance crisis is overdosage and self-medication. 302][33] In this study, we report that high education level, monthly income, good practice, and good knowledge were significantly associated with a reduced likelihood to self-medicate.Pregnant women who have had primary, secondary, and tertiary had reduced odds of self-medicating with antibiotics.In a study conducted in Lebanon by Jamhour et al., 34 self-medication significantly correlated with a lower educational level.This may be because better medication knowledge is associated with higher educational levels 35 and also increase the odds of maintaining excellent or very good health. 36so, we found out that an increased monthly income is associated with decreased odds of self-medication.Those who earned Gh¢1000-1499, Gh¢1500-1999, and Gh¢2000 or more had reduced odds of self-medicating, in contrast to KAP studies among the South African cohort of pregnant women where women

F I G U R E 1
Percentage of responses from all respondents to statements to determine knowledge towards antibiotic use.

1
Analysis of knowledge level by background and obstetrics characteristics, attitude, and practice.
Percentage of responses from all respondents to statements to determine practice towards antibiotic use.Logistic regression analysis of predictors of knowledge among study participants.
T A B L E 3 Logistic regression analysis of predictors of antibiotic self-medication among study participants.